Unilateral Multicanalicular Vestibular Lithiasis of Right Horizontal and Posterior Semicircular Canals: An Unusual Case

Abstract

Vestibular lithiasis (canalolithiasis as well as cupulolithiasis) commonly exists in monocanalicular forms involving one of the three semicircular canals, frequent posterior, less frequent horizontal, and very rarely anterior. It is treated with canal clearing maneuvers intended to reposition the otoconia from the semicircular canal (where they have inappropriately entered) through the utricular exit in the nonampullary arm of the semicircular canal to the utricle (where they normally remain as a part of utricular gelatinous matrix). The cases of multicanalicular vestibular lithiasis with the involvement of more than one semicircular canal require meticulous identification of the involved canals and multiple different canal-clearing maneuvers for effective treatment. A 70-year-old male patient with no significant history of previous medical or otologic illnesses or head trauma presented with a 1-day history of vertigo with positional aggravation. A one-time performed diagnostic supine head roll test elicited three different patterns of positional nystagmus, each with an accurate localizing and lateralizing value. Diagnosis of unilateral multicanalicular vestibular lithiasis of right horizontal and posterior semicircular canals was entertained based on the pattern of the elicited positional nystagmi on the supine roll test. The upbeating torsional nystagmus that localizes the involvement to the posterior semicircular canal was paradoxically elicited by supine head roll test and not by the Dix–Hallpike test. As horizontal semicircular canalolithiasis causes severe symptoms, its treatment preceded that of concurrent posterior semicircular canalolithiasis. The patient was successfully treated with multiple sessions of canalith repositioning maneuvers (CRMs) spread over 24 hours. It is important to perform both positional tests, namely Dix–Hallpike maneuver, and supine head roll test, in cases suspected to have multicanalicular vestibular lithiasis. The positionings may need to be repeated several times to unveil multiple nystagmi, each with different localizing and lateralizing values. Identifying treatment priorities with CRM for the individual semicircular canals is crucial, and the canal that is liable to cause severe symptoms needs early clearance of the otoconial debris. If a CRM fails to clear a semicircular canal, an alternative maneuver may need to be executed. Clinicians involved in the care of cases with multicanalicular vestibular lithiasis should be well versed with all possible backup maneuvers for clearing each of the three semicircular canals.

Keywords

vestibular lithiasis - multicanalicular - otoconial debris - BPPV - Dix–Hallpike test - supine head roll test

Publikationsverlauf

Artikel online veröffentlicht:
29. September 2021

• References

• 1 De la Meilleure G, Dehaene I, Depondt M, Damman W, Crevits L, Vanhooren G. Benign paroxysmal positional vertigo of the horizontal canal. J Neurol Neurosurg Psychiatry 1996; 60 (01) 68-71
• 2 Honrubia V, Baloh RW, Harris MR, Jacobson KM. Paroxysmal positional vertigo syndrome. Am J Otol 1999; 20 (04) 465-470
• 3 Macias JD, Lambert KM, Massingale S, Ellensohn A, Fritz JA. Variables affecting treatment in benign paroxysmal positional vertigo. Laryngoscope 2000; 110 (11) 1921-1924
• 4 Korres S, Balatsouras DG, Kaberos A, Economou C, Kandiloros D, Ferekidis E. Occurrence of semicircular canal involvement in benign paroxysmal positional vertigo. Otol Neurotol 2002; 23 (06) 926-932
• 5 Sakaida M, Takeuchi K, Ishinaga H, Adachi M, Majima Y. Long-term outcome of benign paroxysmal positional vertigo. Neurology 2003; 60 (09) 1532-1534
• 6 Imai T, Ito M, Takeda N. et al. Natural course of the remission of vertigo in patients with benign paroxysmal positional vertigo. Neurology 2005; 64 (05) 920-921
• 7 Nakayama M, Epley JM. BPPV and variants: improved treatment results with automated, nystagmus-based repositioning. Otolaryngol Head Neck Surg 2005; 133 (01) 107-112
• 8 Cakir BO, Ercan I, Cakir ZA, Civelek S, Sayin I, Turgut S. What is the true incidence of horizontal semicircular canal benign paroxysmal positional vertigo?. Otolaryngol Head Neck Surg 2006; 134 (03) 451-454
• 9 Moon SY, Kim JS, Kim BK. et al. Clinical characteristics of benign paroxysmal positional vertigo in Korea: a multicenter study. J Korean Med Sci 2006; 21 (03) 539-543
• 10 Jackson LE, Morgan B, Fletcher Jr JC, Krueger WW. Anterior canal benign paroxysmal positional vertigo: an underappreciated entity. Otol Neurotol 2007; 28 (02) 218-222
• 11 Chung KW, Park KN, Ko MH. et al. Incidence of horizontal canal benign paroxysmal positional vertigo as a function of the duration of symptoms. Otol Neurotol 2009; 30 (02) 202-205
• 12 Katsarkas A. Benign paroxysmal positional vertigo (BPPV): idiopathic versus post-traumatic. Acta Otolaryngol 1999; 119 (07) 745-749
• 13 Tomaz A, Ganança MM, Ganança CF, Ganança FF, Caovilla HH, Harker L. Benign paroxysmal positional vertigo: concomitant involvement of different semicircular canals. Ann Otol Rhinol Laryngol 2009; 118 (02) 113-117
• 14 Korres S, Balatsouras DG, Ferekidis E. Prognosis of patients with benign paroxysmal positional vertigo treated with repositioning manoeuvres. J Laryngol Otol 2006; 120 (07) 528-533
• 15 Bertholon P, Chelikh L, Tringali S, Timoshenko A, Martin C. Combined horizontal and posterior canal benign paroxysmal positional vertigo in three patients with head trauma. Ann Otol Rhinol Laryngol 2005; 114 (02) 105-110
• 16 Shim DB, Song CE, Jung EJ, Ko KM, Park JW, Song MH. Benign paroxysmal positional vertigo with simultaneous involvement of multiple semicircular canals. Korean J Audiol 2014; 18 (03) 126-130
• 17 Leopardi G, Chiarella G, Serafini G. et al. Paroxysmal positional vertigo: short- and long-term clinical and methodological analyses of 794 patients. Acta Otorhinolaryngol Ital 2003; 23 (03) 155-160
• 18 Aw ST, Todd MJ, Aw GE, McGarvie LA, Halmagyi GM. Benign positional nystagmus: a study of its three-dimensional spatio-temporal characteristics. Neurology 2005; 64 (11) 1897-1905
• 19 Ichijo H. Positional nystagmus of horizontal canalolithiasis. Acta Otolaryngol 2011; 131 (01) 46-51
• 20 Domènech-Vadillo E, Álvarez-Morujo De Sande MG, González-Aguado R. et al. Incidence of unilateral and bilateral benign paroxysmal positional vertigo when the left and right Dix-Hallpike manoeuvres are positive: a model based on the sense of torsional nystagmus. Acta Otorhinolaryngol Ital 2020; 40 (02) 144-151
• 21 Bronstein AM. Vestibular reflexes and positional manoeuvres. J Neurol Neurosurg Psychiatry 2003; 74 (03) 289-293
• 22 Ewald JR. Physiologische Untersuchungen Ueber das Endorgan de Nervus Octavus. Wiesbaden, Germany: Bergmann JF Publishers 1892
• 23 Bhattacharyya N, Gubbels SP, Schwartz SR. et al. Clinical practice guideline: benign paroxysmal positional vertigo (update. Otolaryngol Head Neck Surg 2017; 156 (Suppl. 03) S1-S47
• 24 Strupp M, Fischer C, Hanβ L, Bayer O. The takeaway Frenzel goggles: a Fresnel-based device. Neurology 2014; 83 (14) 1241-1245
• 25 Ciniglio G Appiani, Catania G, Gagliardi M. A liberatory maneuver for the treatment of horizontal canal paroxysmal positional vertigo. Otol Neurotol 2001; 22 (01) 66-69
• 26 Asprella GL, Gufoni M. Vertigine parossistica da CSL: manovre di barbecue ed altre varianti. In: Nuti D, Pagnini P, Vicini C, eds. Atti della XIX Giornata di Nistagmografia Clinica. Milano: Formenti 1999: 321-336
• 27 Mandalà M, Pepponi E, Santoro GP. et al. Double-blind randomized trial on the efficacy of the Gufoni maneuver for treatment of lateral canal BPPV. Laryngoscope 2013; 123 (07) 1782-1786
• 28 Tusa RJ. Vertigo. Neurol Clin 2001; 19 (01) 23-55, v
• 29 Radtke A, von M Brevern, Tiel-Wilck K, Mainz-Perchalla A, Neuhauser H, Lempert T. Self-treatment of benign paroxysmal positional vertigo: Semont maneuver vs Epley procedure. Neurology 2004; 63 (01) 150-152
• 30 Pagnini P, Nuti D, Vannucchi P. Benign paroxysmal vertigo of the horizontal canal. ORL J Otorhinolaryngol Relat Spec 1989; 51 (03) 161-170